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CLINICAL SUPERVISION VERIFICATION

For LGSW and LISW

INSTRUCTIONS TO COMPLETE THIS FORM

PLEASE TYPE OR PRINT CLEARLY IN BLACK INK AND KEEP ALL PAGES OF THIS FORM TOGETHER. 1. Each of your supervisor(s) must complete and submit a separate form. This form may be duplicated. 2. Attach a job description to this form, which corresponds to the position being documented, if not previously submitted. 3. Complete page 1. Then submit the entire form to your supervisor for completion of pages 2, 3, and 4. Your supervisor must submit all pages of this form directly to the Board. Please Note: This form will be reviewed at time of renewal or when applying for a different license.

(Revised August 1, 2011)

LICENSEE/APPLICANT INFORMATION

(Applicant/licensee must complete this section.)

CIRCLE THE APPLICATION FORM THAT YOU ARE SUBMITTING WITH THIS SUPERVISION VERIFICATION FORM:

LICENSURE APPLICATION LICENSURE RENEWAL NOT SUBMITTED WITH AN APPLICATION or RENEWAL YES NO

HAVE YOU PREVIOUSLY SUBMITTED A SUPERVISION PLAN FOR THE SUPERVISED

PRACTICE REPORTED ON THIS FORM? (circle) LICENSE NUMBER: CURRENT LICENSE HELD: (circle) LGSW clinical scope

LISW clinical scope MIDDLE NAME:

LAST NAME (as it appears on license card) MAILING ADDRESS: (NEW? circle: YES NO) CITY: COUNTY:

FIRST NAME: E-MAIL ADDRESS:

STATE: FAX:

ZIP CODE:

DAYTIME PUBLIC TELEPHONE:

LICENSEE/APPLICANT POSITION INFORMATION SUBMITTED

AGENCY/EMPLOYER NAME FOR POSITION REPORTED ON THIS FORM (may be different from current employment):

AGENCY ADDRESS:

CITY: LICENSEE/APPLICANT'S POSITION TITLE:

COUNTY:

STATE:

ZIP CODE:

RECORD FULL-TIME & PART-TIME PRACTICE DATES & NUMBER OF PART-TIME HOURS PER WEEK FOR THE POSITION REPORTED

FULL-TIME PART-TIME

FROM: (mo/yr)

TO: (mo/yr) NUMBER OF HOURS PER WEEK:

FROM: (mo/yr)

TO: (mo/yr)

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SUPERVISOR SECTION INSTRUCTIONS FOR SUPERVISOR

PLEASE TYPE OR PRINT CLEARLY IN BLACK INK AND KEEP ALL PAGES OF THIS FORM TOGETHER. All Supervisors: 1. Complete pages 2, 3, and 4. 2. Review the attached position description, if applicable. 3. Submit all pages of this form directly to the Board office at the address listed on the form. 4. Attach the Detailed Description of Clinical Social Work Practice to this form (instructions on page 4).

SUPERVISOR INFORMATION

(Supervisor must complete this section.)

LAST NAME: MAILING ADDRESS: CITY: LICENSE NUMBER: (Identify if other than Minnesota) HIGHEST DEGREE: PRESENT EMPLOYER: ADDRESS: CITY: TITLE AT TIME OF SUPERVISION: MAJOR: EFFECTIVE DATE OF LICENSE: DATE DEGREE CONFERRED: SUPERVISOR EMAIL: DAYTIME PUBLIC TELEPHONE: STATE: OTHER BOARD LICENSURE: ZIP CODE: STATE: ZIP CODE: LICENSE HELD: COLLEGE OR UNIVERSITY: FIRST NAME: MIDDLE NAME:

SUPERVISOR'S REPORT OF SUPERVISION PROVIDED PRIOR TO AUGUST 1, 2011

Dates of Supervision: FROM: (mo/yr) TO: (mo/yr) List average number of hours for each type of supervision provided per month below:

In-person one-on-one supervision: ________

NOTE:

In-person group supervision: _______

Electronic supervision: ________

Number in group, excluding supervisor(s): ________

At least ½ of the supervision must be in-person one-on-one supervision. In-person group supervision may not exceed more than ½ of the required hours. Electronic supervision may not exceed more than 1/3 of the required hours. Group supervision may not exceed 7 members, including licensed social work supervisor.

SUPERVISOR'S REPORT OF SUPERVISION PROVIDED ON OR AFTER AUGUST 1, 2011

Dates of Supervision: FROM: (mo/yr) TO: (mo/yr) For the dates listed above, provide the following: Total number of practice hours Total number of "direct clinical for which supervision was provided___________ Total number of supervision hours_____________ client contact" hours____________ For the dates listed above, provide details of the total number of supervision hours reported: Mandatory One-on-One Supervision Hours (50% required) Total In-Person hrs _________ (minimum 25%) Total Eye-to-Eye electronic media hrs _________ Other Types of Supervision Permitted (no more than 50% allowed) Total One-on-One telephone hrs_________

Total Group hrs_________ (may include in-person, telephone, or eye-to-eye electronic media) Number in group, excluding supervisor(s) ________ NOTE: "Direct clinical client contact" is only required if supervisee is engaged in clinical practice and the effective date of their LGSW or LISW license is on or after August 1, 2011. "Direct clinical client contact" means in-person or electronic media interaction with a client, including client systems and service providers, related to the client's mental and emotional functioning, differential diagnosis, and treatment. Group supervision is limited to six supervisees. Supervision must not be provided by e-mail.

LICENSEE/APPLICANT NAME & LICENSE NUMBER:____________________________________________________________ 2

RECOMMENDATION/CERTIFICATION BY THE SUPERVISOR (Supervisor must complete this section by circling response.)

Yes No As a supervisor, you have completed a one-time requirement of 30 hours of training in supervision, and you understand this information will be available to the public. If you signed a Supervision Plan for the licensee/applicant, do you affirm that the supervision provided for the position documented within this form was carried out as described previously in the Supervision Plan considered and approved by the Board? Is the position description which the licensee/applicant has attached (if applicable) to this form an accurate reflection of the licensee/applicant's practice? If not, please attach an explanation. Do you attest that the supervisee has not engaged in conduct in violation of the Standards of Practice specified in the Board's Statute, Chapter 148E.195 to 148E.240? Do you attest that the supervisee has practiced competently and ethically in accordance with professional social work knowledge, skills and values? If not, please attach an explanation. Do you affirm that the content of the supervision has included clinical practice? Do you affirm that the content of the supervision has included: Yes Yes Yes Yes Yes No No No No No 1. development of professional social work knowledge, skills, and values 2. practice methods 3. authorized scope of practice 4. ensuring continuing competence 5. ethical standards of practice

Yes

No

Yes

No

Yes Yes

No No

Yes

No

Affirmation: I hereby affirm that I directly supervised the named licensee/applicant and affirm that the supervisee has met the applicable supervised practice requirements. I also affirm that the information I have provided is true and correct to the best of my k nowledge. I understand that this information will be used to evaluate the supervisee's compliance with requirements for licensure as a social worker.

SUPERVISOR NAME: (please print) SUPERVISOR SIGNATURE:

LICENSE HELD & LICENSE NUMBER: DATE:

Classification of Data: Information which you and your supervisor provide on this form is classified as private data prior to licensure and is accessible only to you, Board members and staff, the Board's legal counsel, and persons whom you designate. W hen your application is approved, the information provided on this form and all other information related to your supervision verification will be classified as public data. Public data is available to any person upon request. The purpose and intended use of this information is to enable the Board to determine whether the documented supervised practice meets statutory requirements for licensure. You are not legally required to provide this information, but the Board will not be able to take action without this information.

SUPERVISOR: PLEASE RETURN THE ORIGINAL FORM DIRECTLY TO THE BOARD OFFICE ADDRESS LISTED ON THE TOP OF THE FIRST PAGE. PLEASE MAKE A COPY OF THIS FORM FOR YOUR RECORDS.

LICENSEE/APPLICANT NAME & LICENSE NUMBER: _____________________________________________________

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SUPERVISOR REPORT OF CLINICAL SOCIAL WORK PRACTICE

(Only supervisors reporting Clinical Social Work Practice complete this section.) INSTRUCTIONS FOR DETAILED DESCRIPTION OF CLINICAL SOCIAL WORK PRACTICE ATTACHMENT Minnesota Statutes, Chapter 148E.010, subdivision 6: "Clinical practice" means applying professional social work knowledge, skills, and values in the differential diagnosis and treatment of psychosocial function, disability, or impairment, including addictions and emotional, mental, and behavioral disorders. Treatment includes a plan based on a differential diagnosis. Treatment may include, but is not limited to, the provision of psychotherapy to individuals, couples, families, and groups. Clinical supervisors must verify clinical social work practice by attaching a completed Detailed Description of Clinical Social Work Practice for the licensee/applicant which must be signed by all supervisors. If the supervisor(s) have already submitted a signed Detailed Description of Clinical Social Work Practice for this position, a duplicate description is not required. Please note that it is important to be as specific and thorough as possible. A reference to the attached position description will not be sufficient. Please attach a typewritten narrative signed by your supervisors which describes each of the following elements: 1. Client population and the range of presenting issues/diagnoses 2. Clinical modalities commonly utilized 3. Diagnostic process, including: a) process utilized for determining clinical diagnoses, b) diagnostic instruments used, and c) role of the licensee/applicant in the diagnostic process. RECOMMENDATION/CERTIFICATION BY THE SUPERVISOR OF CLINICAL PRACTICE

Yes No As a clinical supervisor, I have completed at least 2000 hours of experience in authorized social work practice, including 1000 hours of experience in clinical practice, after obtaining my LICSW license. I understand this information will be available to the public. I affirm that the licensee/applicant has practiced clinical social work and has demonstrated skill through practice experience in the differential diagnosis and treatment of psychosocial function, disability, or impairment, including addictions and emotional, mental, and behavioral disorders. I affirm that the attached Detailed Description of Clinical Social Work Practice accurately reflects the licensee/applicant's scope of practice. A Detailed Description of Clinical Social Work Practice for this position signed by this supervisor is not being submitted with this form because it has been submitted with previous supervision documents. SUPERVSIOR LICENSE HELD & LICENSE NUMBER: DATE:

Yes

No

Yes

No

Yes

No

SUPERVISOR NAME: (please print) SUPERVISOR SIGNATURE:

NAME OF LICENSEE/APPLICANT SUBMITTED FOR:

LICENSEE/APPLICANT LICENSE NUMBER:

SUPERVISOR: PLEASE RETURN THE ORIGINAL FORM DIRECTLY TO THE BOARD OFFICE ADDRESS LISTED ON THE TOP OF THE FIRST PAGE. PLEASE MAKE A COPY OF THIS FORM FOR YOUR RECORDS.

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